MEDICARE: MIND RESOLUTIONS CLINICAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1487249652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND RESOLUTIONS CLINICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	2006 S 10TH ST APT D
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-5341
Country	:	US
Telephone Number	:	772-216-3270
Fax Number	:

Provider Business Practice Location Address
First Line	:	2006 S 10TH ST APT D
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-5341
Country	:	US
Telephone Number	:	772-216-3270
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	SADE BLACKSHEAR
Credential	:	LMHC
Telephone Number	:	772-216-3270

Provider Enumeration Date	:	03/09/2021
Last Update Date	:	03/09/2021

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